Finance Chapter 3

Question 1

When was the start of direct reimbursement for NP services by Medicare and what was it limited to?

Answer 1

1990; limited to NPs in rural areas and SNFs

Question 2

Medicare amended its reimbursements of APRNs to include _____. when was this?

Answer 2

include all geographical regions including clinical nurse specialist, nurse midwife, and nurse ANESTHETIST services. 1997

Question 3

Describe INcident-To Versus Direct Billing percentages

Answer 3

If billed directly, NP are reimbursed at 85% of the physician fee schedule.

If billed as incident-to physician billing, then reimbursement is 100%.

Many practices bill NP services as incident-to, making it difficult to calculate the NP contribution

Question 4

Requirements for Incident-To Billing (7 total)

ALL must be met

Answer 4

1. Services provided to Medicare beneficiary
2. Services are in “noninstitutional setting” and not in a Federally Qualified Health Center
   or Rural Health Center
3. Must be a follow-up visit with an already established plan of care
4. Care must be provided under “direct supervision” of physician
5. Physician must “actively” participate in and manage course of treatment
6. Both physician and NP must be employed by the same entity
7. The service must be of a type usually performed in the office setting and part of the
   normal course of treatment

Question 5

Current Procedural Terminology (CPT)

Answer 5

codes that describe medical, surgical, and diagnostic services

New pt if was not seen within 3 years
- E&M
- The four levels of care present for new and established patients are: straightforward, low, moderate, and high.
- Must include a medically appropriate history and/or examination

Question 6

The evaluation and management (E&M)

Answer 6

services guidelines, which have seven components (nature of presenting problem, history, physical examination,
medical decision-making, counseling, coordination of care, and time)

Question 7

A standard language is
used to record and classify care:

Answer 7

• CPT
• E&M
  -ICD-10-CM codes

Question 8

International Statistical Classification of Diseases and Related Health
Problems (ICD) codes identify the disease, sign, symptom, or complaint

Answer 8

• Allow specificity for complexity of the diagnosis or complications
• Currently using 10th edition, plans for 11th edition
• Overseen by the World Health Organization in cooperation with the
  National Center for Health Statistics in the United States, so allows for international data sharing

Question 9

The most important things for a DNP to understand is

Answer 9

• Payer Mix of Practice and of NP
• Average Number of Visits
• Most Commonly Used E&M Codes
• Overhead Costs

Question 10

Payer Mix is

Answer 10

to the proportions of payments received from each kind of payer—federal, state, private, or self-pay. In short, payer mix tells you the types of patients coming to your facility.

Question 11

Overhead costs

Answer 11

costs represent the cost of doing business. Included in this amount are the salaries of support staff, cost of benefits, facility fees, utilities, and licensing.

Question 12

Population health

Answer 12

an approach used to improve the
health of a community using nontraditional partnerships among various institutions such as government agencies, educational institutions, healthcare organizations, and so on

Question 13

Increasing NP scope of practice leads to

Answer 13

more accessible care in underserved areas and reduces costs by reducing emergency room use
- estimated : annual Medicare cost savings of US$44.5 billion nationally

Question 14

Calculate NP Contribution*** ask kourtney about adding table example from slide 11 and 12

Question 15

1. Examine the Nurse Practice Act in your state. What opportunities exist for APRNs to expand their scope of practice? What can you do to effect legislative change?

Question 16

2. a. What is your current contribution to the practice you are involved with? Calculate the revenue you generate and your contribution to patient health as measured by obesity, blood pressure control, or other relevant metrics.
   b. Based on your revenue calculations, evaluate the overhead costs in your practice and whether changing the composition of the care team could enhance quality, decrease cost, or both.

Question 17

3. Identify sources of revenue for your practice from various forms of insurance. What opportunities exist in your practice to attract a more favorable payment mix?

Question 18

4. Identify the ideal patient mix for all practitioners in your practice. Consider the diagnosis mix, skill sets of practitioners, and limitations to scope of practice in your state as well as payer mix of the patients in your current practice.